11 July 2016
Nora Cooke O'Dowd

Nora Cooke O'Dowd

Research Analyst
QualityWatch

This month our updated indicators relate to the key headline performance measures for the NHS. We look at waiting times and delays across emergency care, diagnostic tests, treatment after referral, urgent cancer referrals and transfers of care.

Emergency care: Ambulance calls and A&E

It is now 27 months since the target was met of 75% of Category A (life-threatening) calls being responded to within 8 minutes. The number of category A calls that result in an emergency response rose 33% from 2.5 million in 2011/12 to just under 3.4 million in 2015/16. In most months when there is a breach of the eight minute response target nationally, there is a corresponding breach in more than half of ambulance trusts. This suggests that a breach of the national target is due to common factors across areas rather than just poorer performance in a few outlier trusts.

In Q4 2015/16, 82% of arrivals to major A&E were admitted, transferred or discharged within 4 hours, the poorest performance since the introduction of the four hour target. The target that 95% of people visiting major A&E should be seen in four hours has not been met since Q2 2012/13. Waiting times are associated with the normal seasonal fluctuations, but breaches are no longer seen only in non-winter months, as highlighted in our Winter pressures report. The median waiting time remained at around 130 minutes until the second half of 2014 but began increasing after that and peaked at 156 minutes in February 2016. Admitted patients spend an average of 111 minutes longer in A&E than non-admitted patients. The median time spent by admitted patients reached a new high of 238 minutes in February 2016, just short of the 4 hour mark.

For more background and analysis on this area see our 2014 report Focus On: A&E Attendances. We also looked into the effect of distance from home for emergency care

Dr Clifford Mann, President of the Royal College of Emergency Medicine, has written a blog exploring ways to tackle some of the issues raised by these data. 

Diagnosis

No more than 1% of patients should wait longer than 6 weeks for a diagnostic test following referral from a GP. This target has not been met since November 2013, hovering around 2%. The introduction of national targets initially had a big impact on clearing the waiting list, which fell to almost 400,000 in December 2008. Since then, the list has been steadily increasing to just under 870,000 in April 2016. However, this should be seen in the context of rapidly increasing number of diagnostic tests undertaken each month: 816,000 in January 2006, and 1.7m in January 2016. Median waiting times have stayed fairly stable at around 2 weeks since January 2008 with some variation and an expected peak in December every year.

Treatment

The NHS Constitution gives patients the legal right to treatment within 18 weeks of referral. The proportion of people treated within 18 weeks of referral has been consistently high since the introduction of targets. Since June 2015, there has been a single target that 92% of referred patients should start treatment within 18 weeks. This target was breached for the first time in December 2015 and again in March and April 2016. By April 2016, only 79% of people whose treatment involved an inpatient hospital admission received treatment within 18 weeks. This remained at 92% for patients who did not need to be admitted. The number of people on the treatment waiting list has increased from 2.4 million in December 2009 to 3.3 million in December 2015, while treatment activity has remained constant. The median wait has remained roughly stable, but has increased for non-admitted patients.

There has been an overall increase in the number of cancelled elective operations, within seasonal variation and a peak in Q4 each year. There were 8,714 more cancelled elective operations in Q4 2014/15 than Q4 1994/95 - this represents a 60% increase over 20 years. In Q4 2014/15 there were 23,180 elective operations cancelled from a total of nearly two million elective admissions (1.2%). The proportion of cancelled elective operations has been decreasing since 2004/05, in spite of the growing number of elective admissions (62%), suggesting that not only has the NHS been able to cope with the increasing demand but it has been able to improve on previous performance.

The NHS constitution pledges that if a hospital cancels an operation at the last minute for non-clinical reasons, it should offer a new date for the operation within 28 days. The proportion of patients whose elective operations were cancelled and not treated within 28 days has decreased over time: between Q4 1994/95 and 2014/15 it dropped almost 6 percentage points.

Cancer waiting times after urgent referral

The proportion of people seen within two weeks of an urgent referral to a cancer specialist fluctuated between 95% and 96% from Q3 2009/10 to Q4 2013/14, and failed to meet 95% in any quarter since then. 96% of patients should receive their first cancer treatment within 31 days of a decision to treat; this target has been comfortably met since 2008/9. However, this measure dropped by roughly one percentage point in 2014/15. Given the numbers who receive a decision to treat (69,001 in Q4 2015/16) a single percentage point increase represents a lot of people. Almost 100% of people with a decision to treat receive drug treatment within 31 days, but this drops for those awaiting surgical treatment (95%, Q4 2015/16).

Delayed transfers of care

The number of patients experiencing a delayed transfer of care has been increasing since January 2014, with just fewer than 6,000 patients experiencing a delay in April 2016. There has been a steep increase in the total number of delayed days since April 2014, rising just under 170,000 days in April 2016. These increases stem from acute care, while non-acute care has seen a small decrease in delays. The number of days delayed per month in acute care has increased by 104% between August 2010 (55,332 days) and April 2016 (112,720 days). The increase in delays owing to the NHS is steeper than delays owing to social care, although this is also increasing.

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